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Educational Issues and School Reentry for StudentsWith Traumatic Brain Injury

Ann Glang, Debbie Ettel, Janet Siantz Tyler, Bonnie Todis

INTRODUCTION

Each year, approximately 40% of traumatic brain injuries(TBIs) in the United States occur in the pediatric population(ages 0–19 years) (1). The Centers for Disease Control (CDC)estimates that more than 60,000 children and adolescents arehospitalized annually in the United States after sustainingmoderate-to-severe brain injuries from motor vehicle crashes,falls, sports, and physical abuse; an additional 631,146 chil-dren are seen in hospital emergency departments and re-leased (1). In all, nearly 145,000 children aged 0–19 years arecurrently living with long-lasting, significant alterations insocial, behavioral, physical, and cognitive functioning follow-ing a TBI (2).

Reduced federal funding and managed care have re-sulted in shorter inpatient rehabilitation stays for patients,fewer services dedicated to families, and lack of access toongoing rehabilitative services (3,4). Increasingly, childrenwith mild-to-moderate TBI are released from treatment withno plans for long-term rehabilitation support. The result isthat children who may have intense physical and/or cogni-tive needs return home to families who are largely responsi-ble for supporting them through the rehabilitation processwith little or no support from medical or community-basedagencies (5,6). As a function of shortened hospital stays andthe chronic problems arising from pediatric TBI, the primaryservice provider for children and adolescents has becomethe school. This chapter will describe the challenges studentswith TBI present to schools and strategies schools can useto address them.

OVERVIEW OF IMPACT OF TRAUMATIC BRAININJURY ON SCHOOL PERFORMANCE

Predicting the impact of a pediatric TBI on school perfor-mance is difficult, in part because no 2 injuries are alike, andalso because the same etiological factor can cause diverseoutcomes depending on the child and the context. Research-ers (7) suggest that several variables influence student out-comes, including (a) the child’s age at injury (8), (b) theseverity of the TBI (9), (c) premorbid behavioral and learn-ing status (10,11), (d) history of previous injury (12–15), and(e) postinjury pain or stress (16,17).

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Academic Achievement, Executive Dysfunction,and Social Behavior Problems

Although the impact of pediatric TBI on a child’s schoolperformance is unique and dynamic, some general charac-teristics typify the course of impact and recovery (7). Themost reported TBI sequelae related to school performanceare (a) a progressive lag in academic achievement (18–21),(b) executive dysfunction, and (c) social and behavioral prob-lems (22–24).

Academic AchievementMost children make academic gains postinjury, but for stu-dents with moderate to severe injury, the rate of academicachievement gains tends to slow progressively over time,and the effects are long-term (18,25,26). Researchers (27)found that children with moderate TBI showed impairedacademic skills both postacutely and chronically, whereasthose with severe TBI showed greater impairment with onlypartial recovery in certain areas over time. One critical factorin children’s lag in academic achievement was cognitive def-icit as a result of brain injury.

In young children with TBI, recovery of cognitive skillsacross time may show no improvement (28) or may actuallydecline (29), demonstrating a failure to develop age-appro-priate cognitive skills at typical rates. These cognitive deficitscan be parsed into components of executive dysfunction,memory problems, diminished attention and impulse con-trol, and information processing problems, all areas criticalto learning and school success (30–32). Notably, some effectsare immediate, and some sequelae may not become apparentuntil the child returns to the school environment or muchlater, when the demands for competence in reasoning, execu-tive functioning, self-regulation, and social skills increase(33,34). Because TBI cognitive sequelae are diverse and dy-namic, educator awareness is critical to providing studentswith appropriate monitoring and support as needs and is-sues change, sometimes dramatically, over time.

Executive DysfunctionDisruptions in executive function (EF), characterized byskills in attentional control, planning, goal setting, problem

2 VI. REHABILITATIVE CARE AND TREATMENT OF SPECIFIC POPULATIONS

solving, cognitive flexibility, and abstract reasoning, canoccur as a result of direct damage to frontal regions or fromdisruption of connections among these and other brainregions. Because EF orchestrates so many domains of cogni-tion, emotion, and behavior, the functional results of exe-cutive dysfunction are multidimensional and debilitating(35–37).

At the root of many of the academic, social emotional,and behavioral issues that can follow a TBI are problemswith self-regulation, the internal control functions that directand organize all nonreflexive or nonautomatic behavior,including social, cognitive, and linguistic behavior (38). Thesame regulatory deficits that underlie learning problems(e.g., trouble focusing on classroom work, irritability, andimpulsiveness) can also negatively affect social-emotionalbehavior and interpersonal relationships with peers andadults (39–42). For example, self-regulation skills requiredin a school setting include keeping hands and feet to oneself,taking turns in a conversation, and maintaining an emotionalstate appropriate to the school context. Neural systems thatregulate these behaviors might be compromised, makingboth appropriate academic behavior and interpersonal be-havior challenging for students.

In a school setting, deficits in EF can manifest as impul-siveness, poor social judgment, disorganization, social disin-hibition, weakly regulated attention, slowed processing,ineffective planning, and reduced initiation (31,33). Becauseof difficulty with organization and attention, educatorsmight observe students having problems managing their as-signments, gathering materials, starting on tasks, or stayingon task. In addition, some students struggle with transitionsfrom one class to the next, and they might have difficultysequencing multistep procedures or recalling assignments.Thus, executive dysfunction in the classroom presents myr-iad challenges for students with TBI.

After TBI, students may perform poorly on tasks of sus-tained, selective, and shifting attention (43). A student mayhave difficulty concentrating for extended periods, perform-ing 2 tasks simultaneously (such as listening while takingnotes), or completing 1 task and switching attention to anew task. Lack of attentional flexibility can also result indiminished problem solving skills. For example, a studentwho loses a pencil might not be able to generate problem-solving ideas for replacing it. Both initiation skills and atten-tional flexibility are needed to keep the lack of a pencil frombeing an insurmountable barrier to work completion. Forchildren with mild injury, inattention and behavior chal-lenges were the most frequently reported problems (44).

The speed with which students process informationmay change dramatically after a TBI (43). Students may takelonger to respond to teacher questions or instructions, orthey may need longer to complete tasks or process teacherdirections. This greater response latency can be misinter-preted as refusal to respond or begin work. Students shouldbe allowed adequate time to process and comprehend as-signments (45). Language production and processing canalso be impaired, resulting in problems in word finding, lan-guage fluency, receptive language comprehension, readingcomprehension, and writing skills.

TBI often results in memory problems (sensory, work-ing, and/or long-term memory; retrograde and anteriorgrade amnesia) that can negatively affect the assimilation of

new material or skills (46–48). It has been found (49) thatamong young children, skills emerging at the time of braininjury were more vulnerable to disruption than skills alreadylearned. Previously learned skills might be intact or compro-mised, and difficulties with working memory can negativelyaffect the child’s ability to learn new material. Educatorsmight notice uneven academic performance, with somelower level skills missing while more sophisticated skills re-main intact, making appropriate instruction more chal-lenging.

Social Behavioral ProblemsSocial dysfunction might be the most debilitating of all theTBI sequelae, affecting not only functional aspects of dailyliving but also quality of life (50). Unfortunately, much ofthe research focus has been on the effect of TBI on physicaland cognitive domains, and social-emotional skills have notreceived as much attention. Children with an early braininjury (especially before 2 years of age) are at risk of signifi-cant social impairment (50). Social and emotional problemscan become increasingly apparent during the transition fromchildhood to adolescence, when expectations for the use ofappropriate social skills increase (51–53). Students with TBImight display disruptive behavior, emotional distress, poorconduct, and problems with empathy, moral reasoning, andpeer relationships (35). Addressing potential social behaviordeficits is just as critical to successful school functioning asaddressing academic and cognitive skills—perhaps more so(54–56).

Sometimes overlooked is the emotional grief, sadness,or anger resulting from loss of preinjury abilities or identity.Even years after their injury, adults who sustained a child-hood TBI report differences in self-concept postinjury, withthe current self viewed more negatively than the preinjuryself, and development of new identity as an ongoing process(57). Unfortunately, counseling or therapeutic support ad-dressing post-traumatic stress or grief is often lacking forstudents with TBI. Grief and recovery from emotionaltrauma, especially when combined with poor impulse con-trol, can lead to unpredictable emotional outbursts, irritabil-ity, labile affect, and depression. Educators might observesocial withdrawal behaviors, poor adaptive behaviors, or ap-parent egocentrism as a result (58,59). The combination ofthese deficits can also result in problems with delinquencyif not identified and addressed with appropriate interven-tion and support. High rates of incarceration among peoplewith TBI have been noted (60).

A commonly noticed area of concern is lack of self-awareness, particularly of students’ own skill deficits. Forexample, a student might express an emotional responseinappropriate for a given situation (e.g., laughing when dis-cussing a serious topic) and remain unaware of the inappro-priateness of the action despite negative reactions frompeers. These deficits in insight can cause misperceptions ordistortions of social cues and interactions, affecting how thestudent relates to others or interprets their intentions andbehaviors, resulting in confusion, misunderstanding, andconflict. Peers may be frustrated with the student if he orshe misses important social cues, fails to regulate behaviorssuch as talking out of turn, or denies postinjury deficits andrejects support offered. Ironically, some research (58) hasfound awareness of the discrepancy between the preinjury

37. EDUCATIONAL ISSUES AND SCHOOL REENTRY FOR STUDENTS WITH TRAUMATIC BRAIN INJURY 3

and current (postinjury) self negatively correlated with self-esteem and positively correlated with depression; that is,lack of self-awareness is associated with 1 set of problems,whereas increased awareness has its own array of psycho-logical costs (61).

Other functional areas pertinent to school performanceinclude perceptual skill deficits and physical impairment.Sensorimotor changes can occur, resulting in increased sensi-tivity to environmental stimuli such as hypersensitivity tolight and sound or diminished ability to screen out back-ground sounds. For example, students who once had no dif-ficulty copying notes from a blackboard might find the taskcoordination difficult because of visual–motor changes(62,63). Classrooms are highly stimulating environments—visually, aurally, and kinesthetically—that can overtax thecognitive abilities of a student in recovery from a brain in-jury. A student with poor impulse control might react inap-propriately to such stimuli.

Educators also need to be aware that students can expe-rience extreme fatigue (64), especially early in the postacuterecovery phase when ordinary tasks might require greatermental exertion by the student because of difficulty in pro-cessing, organizing, initiating, and maintaining academicengagement. The student’s physical stamina might be com-promised, requiring increased rest or shortened school daysor class periods to address fatigue and support the recoveryprocess. In addition to fatigue, the student might have sus-tained other physical injuries that can adversely affect schoolperformance. Furthermore, anticonvulsant or other medica-tions may be prescribed prophylactically to reduce the like-lihood of seizures or address behavioral or attentionalconcerns. Educators should be made aware of the intendedand unintended effects of any such prescriptions on studentbehavior, attention, mood, and learning (65).

Mediating and Moderating Factors

Several factors have been found to mediate and moderatethe effects of TBI on school performance. The most com-monly noted factors include (a) age at injury, (b) severity ofinjury, and (c) family environment.

Age at InjuryIt was previously thought that the developing brain wasmore resilient to trauma because of neuroplasticity, the flexi-bility of the young brain to reorganize or reassign tasks fromone functional area to another area (66,67). Newer evidencehas shown that early injury is associated with poorer out-comes than later injury (29,49,68). As young children withTBI develop, behavioral and cognitive problems might con-tinue to emerge (51,69).

Other specific outcomes associated with early injury in-clude deficits in executive functioning, expressive language,attention, academic achievement, and social skills, and lessrecovery of cognitive skills compared with children injuredlater (18,29,68,70–73). Longitudinal studies have shown thatearly age at injury negatively impacts outcomes in likelihoodof postsecondary education enrollment, employment, andindependent living. Early age at injury and severe injurywere associated with employment in primarily entry levelor low-skilled jobs, fewer hours worked per week, and lowerpay for both males and females (29,68).

Injury SeverityIn young children with TBI, severity of injury also predictedpostacute effects on cognitive and school readiness skills,including memory, spatial reasoning, and EF. More severeTBI predicted more negative outcomes (74–78). However,some studies found mixed results of the impact of injuryseverity on outcomes, with severity of injury becoming lesspredictive of outcomes 1 year postinjury (79). A severe injuryat an early age has been associated with the poorest long-term outcomes, including cognitive skill recovery (24,68,80).

Family EnvironmentParticularly in relation to social and behavioral outcomes,family environmental characteristics—such as socioeco-nomic status (SES), overall family functioning, and parentingbehavior—can significantly affect student educational per-formance (26,32,55,81–84). Premorbid child and family func-tioning have been linked to outcomes; children with priorpsychiatric disorders and families already struggling aremore likely to manifest negative postinjury psychosocial ef-fects (80,85–90). Negative social outcomes from TBI are exac-erbated by postinjury family environments that are lowerSES, lacking resources, and have poorer family functioning(55). Other researchers (84) reported a ‘‘double hazard’’ ef-fect in which family socioeconomic disadvantage combinedwith severe injury to lead to the poorest long-term outcomes.Although family variables can moderate psychosocial out-comes for children with TBI (especially behavioral adjust-ment and social competencies), this moderating influencecan wane with time among children with severe TBI (74,91).

Specific parenting behaviors have also been associatedwith children’s outcomes after TBI. It was found (74) thathigh levels of permissive or authoritarian parenting wereassociated with increased behavior problems in childrenwith TBI, particularly for those with severe injury. Pooreroutcomes associated with these parenting styles are in con-trast to those from authoritative parenting, characterized byparental warmth, clear boundaries and expectations, con-sistent rule application, and active parental monitoring.Authoritative parenting was associated with better psycho-social outcomes (74). In general, strong family social supportand cohesion was predictive of students’ better adaptivefunctioning, social competence, and global functioning post-injury (26,82). Other family variables believed to interactwith factors predicting recovery include family expectations,stress and functioning (32,92–94), and genetic vulnerability(95,96). These factors interact with each other to mediate ef-fects, but all predictors also directly affect all outcomes (74).

OUTCOMES BY AGE-GROUP

Preschool-Aged Children

Young children (birth to age 5) who experience a TBI are atgreater risk for deficits in expressive language, attention, andacademic achievement than children who are injured at laterages (18,29,63,68,71,74,97). An early injury affects a develop-ing brain that has not yet formed critical features necessaryfor mature function, potentially interrupting or hinderingthe developmental process. Some suggest that poorer out-comes in children injured early in life might be caused by


the developing brain’s greater susceptibility to diffuse braininsult, resultant abnormalities in neurogenesis, or resultantdifficulties in acquiring new skills postinjury (18,70,71,98,99).Some researchers (70) have stressed the link between earlydevelopmental level and TBI; those injured very youngdemonstrate persistent deficits in academic skills (reading,decoding, comprehension, spelling, and arithmetic). Diffi-culties in global cognitive function, adaptive behavior, EF,and nonverbal abilities have been observed as well (74,97).Others (74) have found that preschool-aged children withTBI had weaknesses in nonverbal abilities and EF and recom-mended the use of memory cues and direct instruction teach-ing methods—structured curricula, multiple presentations,and many opportunities for students to practice new skills.

Children injured when young might present no imme-diately observable deficits; however, such children should bemonitored for the potential emergence of latent TBI sequelaethat might appear as task and setting demands increase. Forexample, behavior difficulties after early injury may not beapparent until the child attends elementary school, whenexpectations for self-regulation, control of attention, and taskcomplexity rise appreciably (100).

School-Aged Youth

Issues for school-aged youth with TBI (grades K–12) becomeheightened as the task and setting demands of school pro-gressively increase. Some (88) have found that children whosustained moderate-to-severe TBI during their school yearswere likely to need special assistance in school at 1 yearpostinjury. Others (101) reported that reading skills are oftencompromised by TBI, and still others have found greateracademic deficits in arithmetic, possibly because of arithme-tic’s necessary component skills in attention, memory, andexecutive functioning (102). Students are expected to becomemore independent learners, demonstrate self-regulatoryskills (staying on task, completing work, keeping hands toself, answering when called on), and master increasinglycomplex skills and more abstract concepts. For the school-aged child with TBI, these can all present challenges in theschool setting. In addition to the academic expectations, thechild’s social focus shifts from family to peers, where inter-personal social skills take on increasing importance andbegin to include communication, negotiation, reciprocal in-teraction, and social participation (54,56,103). In summary,educators need to be aware that school-aged youth with TBImight be challenged by the increasing cognitive, academic,and behavioral demands in the school setting and by theincreasing importance and complexity of their developingsocial relations with peers.

Post-High School Outcomes

A growing body of research indicates that for many studentswith TBI, post-high school outcomes are poor (68,104–106).The second National Longitudinal Transition Study (108)found that fewer than half of students with TBI who hadbeen out of school a year or more had a paid job outside thehome. Young adults (ages 18 years or older) with TBI whoreceived special education were employed and enrolled inpostsecondary education at lower rates than peers in thegeneral population (107).

Furthermore, rates of engagement in employment andpostsecondary training and education remain low through-out early adulthood. In a recent longitudinal study of post-high school outcomes (68), the highest rate of enrollmentin postsecondary education was 34% at age 21. Enrollmentdecreased with being male, earlier age at injury, and lowerSES (68). A key finding was that although few students in-jured before age 14 enrolled in postsecondary education, stu-dents who sustained a TBI during adolescence attemptedto pursue their preinjury college plans, often with negativeresults. Unable to meet academic, social, and independentliving demands, many PSO participants struggled for severalyears before leaving college without degrees. A few wereable to set new goals, discover helpful strategies, and eventu-ally complete 2- or 4-year degree programs (106). Partici-pants in the same study also experienced challenges in thearea of employment, working fewer hours for lower wagesthan their nondisabled peers. None of the student partici-pants worked more than 30 hours per week, and wages aver-aged slightly above minimum wage. At age 25, most stillworked at entry level or low-skilled jobs as their nondisabledpeers were moving up to higher paid, skilled, and profes-sional positions (108). Earlier age at injury and more severeinjury were associated with fewer hours worked per weekand lower pay (68).

In a qualitative study with the same PSO sample, receiptof postsecondary transition services (in which individualswere linked with support agencies and disability services)was associated with completion of postsecondary programs(106). Focus on the modifiable variables that affect postsec-ondary outcomes is important for improving the lives ofstudents with TBI.

MODIFIABLE FACTORS IN TRAUMATIC BRAININJURY OUTCOMES

In addition to child- and family-centered factors, a range ofother external or environmental variables affect outcomesamong children with brain injury. Challenging as it can beto address these factors, they hold promise for improvingoutcomes for students with TBI because they can be modi-fied through improved training and changes in policy andpractice.

Lack of Educator Awareness

Effective educational practices implemented by trained edu-cators can contribute to successful school outcomes for chil-dren and youth with TBI (106). However, many teachersreceive little or no training in childhood TBI (119,110). In arecent survey of educators working with students with TBI,92% reported having no training in the academic effects ofTBI (111). Furthermore, a recent analysis of university text-books revealed that TBI is rarely discussed in current specialeducation texts and is virtually absent from the general edu-cation texts reviewed (112). The lack of information aboutTBI for educators leads to a continued lack of awarenessabout the school-related implications of TBI and absence ofstrategies for addressing them. This lack of awareness leadsto a perception among school personnel that TBI is a ‘‘low-incidence disability,’’ which in turn contributes to the under-identification of children with TBI for special education.

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Underidentification and Misidentification

The most recent special education census data suggest thatthere continues to be a significant discrepancy between theincidence of TBI and the identification of children with TBIfor special education services (113). Approximately 145,000children live with persistent disability following TBI (2).However, according to the most recent figures from the USDepartment of Education, the total number of students re-ceiving special education services under the TBI category is23,509 (114). This rate is likely an underestimate, given that60,000 children are hospitalized each year for TBI (1). Ratesof identification for special education are higher for studentswith severe TBI, problem behavior, poor academic perfor-mance, and socioeconomic disadvantage (88,115–118). Ofparticular concern, given the changing needs of children asthey grow older and school demands increase, is that specialeducation identification rarely occurs after the first year post-injury (118). Although it is likely that some children withTBI receive services under different disability labels (e.g.,speech-language, physical disability, or ‘‘other’’) (118–120),it is unclear whether such services meet the cognitive andbehavioral needs of students with TBI. Because most chil-dren with TBI rely on schools rather than medical settingsfor rehabilitation services, the underidentification and misi-dentification of children with TBI presents a significant ob-stacle to the provision of effective services.

Lack of Hospital–School Communication

There continues to be a weak link between the hospitals thattreat children for TBI and the schools who educate them—interms of both their respective understanding of one another’sworlds and their mutual communication and coordinationefforts (121,122). Between April 1994 and January 1999, theNational Pediatric Trauma Registry tracked children ages5–19 who were hospitalized with TBI in participating traumacenters and children’s hospitals across the United States andwho were discharged to their homes following treatment.Of this group, 13.2% had documented cognitive impairmentsresulting from their brain injury at the time of discharge,and 11.6% had behavioral impairments; yet less than 1% ofthese children were recommended by medical staff for refer-ral to special education (121). A critical modifiable factorcontributing to identification of students with TBI for formalservices is communication and linkage between hospitalsand schools. Although informing educators that a studenthas a TBI does not guarantee that appropriate services willfollow, not being informed by hospital personnel or parentsdecreases the likelihood that educational services will be tai-lored to the student’s specific needs (122).

Parent–Educator Relationships

A critical factor that influences school outcomes for childrenwith TBI is the degree of collaboration between the child’sparents and educators (123). When parents and educatorshave trouble working in partnership, conflicts arise, and thestudent’s education suffers (124–126). Unfortunately, par-ent–professional relationships can easily become adversarialbecause of the many stressors both families and school staff

face in designing educational programs for students withTBI. From the school’s perspective, families often have un-realistic expectations and/or are unable to support theschool’s efforts (127). Parents, on the other hand, often retainpreinjury expectations about academic achievement and per-ceive school staff as having low expectations that do notchange, even as the child’s school performance improves(127). Furthermore, because prior to the injury, most childrenwith TBI progressed typically through school, parents areoften unfamiliar with the provisions of the Individuals withDisabilities Education Act and their role and rights in theeducational process.

EFFECTIVE EDUCATIONAL PRACTICES

Because of the physical, cognitive, academic, and psychoso-cial sequelae of TBI, students may require special educationservices, special assistance, or accommodations on returningto school, with many students continuing to require suchservices throughout their education. From the hospital-to-school transition to the post-high school transition to com-munity-based services, training, and employment, the hub ofthe support system for students with TBI and their families isthe school.

Coordinated Hospital-to-School Transition

One of the most critical points in a child’s rehabilitation pro-cess is at the transition from hospital to school. It is at thispoint that the child can most easily gain access to formalservices through communication between hospital andschool staff (122). Recommendations regarding school reen-try planning include having school personnel observe thestudent in the hospital, attend hospital predischarge meet-ings, and obtain information from the hospital before thechild’s school reentry (128–130). Although it may be difficultunder managed care for hospital staff to fully participate inthe transition process, the hospital–school communicationlink should begin early in the child’s hospital stay, so thatprotocols are in place for hospital staff to alert school staffto those students with brain injuries, even those with mildinjury (131,132). Referral is also needed for students whowere already receiving special education services at the timeof their injury (e.g., for a learning disability or a behaviordisorder), as moderate-to-severe TBI can cause significantadditional cognitive impairment in children with preexistinglearning difficulties, and programming modifications areoften needed after injury (133).

The Individuals with Disabilities Education Improve-ment Act of 2004 (IDEA) (134), provides guidelines for refer-ral, evaluation, eligibility determination, parent involvementin decision-making, individual education plans, and deliv-ery of specially designed instruction and related services.

Given the eligibility requirements of IDEA, and the cur-rent underidentification of students with TBI, TBI research-ers and advocates are exploring ways to assure that allstudents with TBI who need special education services areable to access them. Recent research has demonstrated thatin addition to severity of injury, the provision of hospi-tal–school transition services is strongly related to beingidentified for formal services (either via individual education

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plan [IEP] or 504 plan) (128). Although hospital-to-schooltransition support emerged in this study as a strong predic-tor of being identified for formal special education services,only half (50.9%) of students in this study received any formof transition information or guidance from the hospital.Stated briefly, informing educators that a student has TBIdoes not guarantee that appropriate services will follow, butnot being informed by hospital personnel or parents de-creases the likelihood that educational services will be tai-lored to a student’s specific needs.

Two promising practices are currently being evaluatedand could improve identification processes at the state level.The School Transition Re-entry Program (STEP) is a system-atic notification system designed to increase effective transi-tion from hospital to school (135). Essential elements of thismodel are (a) hospital staff obtain a release from parentsand notify an identified contact at the state Department ofEducation (DOE) about the child, (b) DOE notifies a regionaltransition facilitator that a child who has been treated forTBI is returning to school in that region, and (c) the transitionfacilitator contacts the child’s school and family to offer re-sources and support. Preliminary analyses suggest thatamong students who do not receive hospital rehabilitationservices, students receiving STEP services—systematic tran-sition from hospital to school—are identified significantlymore often for special education than those who do not re-ceive systematic transition. Furthermore, students in theSTEP group received more services, and their parents re-ported significantly greater satisfaction with the school andfound a greater number of school staff helpful comparedwith parents of students in the control group (135). Thus,the STEP intervention appears to provide the essential linkfrom hospital to school previously available only to studentsreceiving rehabilitation services.

A second promising approach systematically tracks andsupports students with mild TBIs as they transition back toschool athletic and academic activities. The Reduce, Educate,Accommodate and Pace (REAP) model is a systematic notifi-cation system to increase effective concussion managementfrom emergency department to school (www.youthsport-smed.com). A person at the emergency department obtainsa release from the family and provides the REAP manual ofconcussion management. That person then faxes the releaseand an information form to an identified contact at a central-ized site. The centralized site contacts a point person at thechild’s school within 48 hours. The point person then coordi-nates concussion management within the school until thechild recovers, tracking and monitoring for latent concerns.Concussion management may also include providing infor-mation on physical and academic accommodations andother ways educators can reduce the cognitive, emotional,and physical load on students recovering from mild TBI.

These are 2 models of systematic communication be-tween hospitals and schools. Central to both models is thepresence of school-based professionals trained in TBI whocan ensure the student receives the support necessary to suc-ceed in school.

Special Education Law

When the provision of special education in public schoolsbecame federal law in 1975 (136), guaranteeing all students

a ‘‘free and appropriate public education,’’ no specific cate-gory for TBI was included. TBI was not introduced as a sepa-rate disability category until 1991 in IDEA. Before that time,students with TBI were identified for special education as‘‘other health impaired’’ or under a specific learning disabil-ity. Some students received services under Section 504 ofthe Rehabilitation Act of 1973, and others were not servedthrough either mechanism (122). Given the long-term effectsof underidentifying students with TBI for special educationservices (137–139), accurate and appropriate assessment iscritical to identify and address students’ needs for educa-tional support (119,140).

Referral ProcessParents, teachers, therapists, medical personnel, or otherscan begin the process of evaluating the child’s educationalneeds by making a referral to the school’s support servicesteam or administrator. The team—made up of teachers, spe-cialists, administrators, and others—is charged with evalu-ating the child’s educational needs in all areas of suspecteddisability and determining whether the student meets eligi-bility criteria (as a child with a disability) to receive specialeducation services. Each category of disability has specificeligibility criteria in the law.

Eligibility for Special Education ServicesTo determine whether a child is eligible for services, anevaluation based on the guidelines specific to the area ofsuspected disability must be conducted. The evaluation re-quirements for TBI are outlined in Table 37-1.

Issues in Assessment and Instruction of Studentswith Traumatic Brain Injury

Because of the diversity within the population of studentswith TBI, there is no one TBI assessment; each assessmentmust be tailored to the student’s unique and changing needs.Several general principles and strategies, however, are rec-ommended to guide educators (34,131,138,142,143). First,accurate interpretation of assessment results requires anunderstanding of the potential effects of TBI on students’learning and response patterns. For example, students’ per-formance may be uneven across academic domains. Theymight show relatively strong performance on material mas-tered preinjury, although evidence of new learning could belacking. Also, because content and skill gaps could be pres-ent throughout the range of skills, examiners might needto suspend typical basal and ceiling rules of standardizedmeasures to more accurately capture student performance.

Second, the potential for both skill recovery and skilldeterioration over time makes ongoing formative assess-ment and frequent monitoring especially important forstudents with TBI (144,145). Educators should rely on eco-logically valid sources of information, such as parent andteacher behavior scales and interviews, curriculum-based as-sessment, and permanent product evaluation, and theyshould choose methods closely tied to instruction and inter-vention (138,146). In addition to being more relevant to in-struction, these measures are more sensitive to small changesin student performance and could prove more beneficial to


TABLE 37-1 IDEA Criteria for Special Education Eligibility Under Traumatic Brain Injury (141)

IDEA CRITERIA FOR ELIGIBILITY UNDER TRAUMATIC BRAIN INJURY

Definition of TBI An acquired injury to the brain caused by an external physical force resulting in total or partialfunctional disability or psychosocial impairment, or both, that adversely affects a child’seducational performance. The term applies to open or closed head injuries resulting inimpairments in one or more areas, such as cognition; language; memory; attention;reasoning; abstract thinking; judgment; problem-solving; sensory, perceptual, and motorabilities; psychosocial behavior; physical functions; information processing; and speech. Theterm does not apply to brain injuries that are congenital or degenerative, or to brain injuriesinduced by birth trauma.

Evaluation must include (a) A medical or health assessment statement indicating that an event may have resulted in aTBI.

(b) A comprehensive psychological assessment, using a battery of instruments to identifydeficits associated with TBI, administered by a licensed school psychologist or the stateBoard of Psychological Examiners or others having training and experience to administerand interpret tests in the battery.

(c) Other assessments, as needed, such as motor, communication, and psychosocialassessments(A) Other information related to the child’s suspected disability, including preinjury

performance and a current measure of adaptive ability.(B) Observation in the classroom and at least 1 other setting.(C) Other additional assessments needed to determine the effect of the suspected

disability on the child’s educational performance for his/her age group.(D) Other assessments needed to identify the child’s educational needs.

Conditions must be met (a) Must have an acquired brain injury caused by external physical force(b) Condition is permanent or expected to last for more than 60 calendar days(c) Injury results in an impairment in 1 or more areas:

(A) Communication(B) Behavior(C) Cognition, memory, attention, abstract thinking, judgment, problem-solving,

reasoning, and/or information processing(D) Sensory, perceptual, motor, and/or physical abilities

The evaluation must determine (a) The child’s disability has an adverse effect on the child’s educational performance(b) The child needs special education services as a result of the disability

Definition of TBI excludes Brain injuries that are congenital, degenerative, or induced by birth trauma

student progress than norm-based measures standardizedon noninjured student populations.

Third, schools could consider bringing neuropsy-chological experts into the planning process by includingindependent neuropsychologists in the assessment of andplanning for students. The neuropsychologist’s expertise inthe clinical and neuropsychological aspects of functioningafter TBI combined with the school psychologists’ familiaritywith academic assessment, instruction, and contextual issueswithin the school setting makes for a comprehensive assess-ment team (146,147). Also, building the capacity of existingstaff by offering further neuropsychological training forschool psychologists and others and improving in-servicefor staff to include basic information on the cognitive, aca-demic, and behavioral profiles of students with TBI can in-crease the capacity of the broader school community (ratherthan a few select individuals) to support these students’unique needs across contexts.

Fourth, contextual assessment is a good framework forassessing the student with TBI in the educational setting(138,148). Contextual assessment, also referred to as ecologi-cal assessment (149), stresses the importance of multisource,multidimensional assessment, gathering relevant informa-tion about the child’s strengths and needs including (a) ob-

servations within the school setting; (b) parent interviews;(c) review of medical records; (d) file review of preinjuryperformance; (e) interviews with medical personnel, includ-ing rehabilitation teachers and home instruction staff; ( f )behavior rating scales and checklists; (g) motor, sensory, andphysical assessments as needed; (h) standardized and curric-ulum-based performance measures; and (i ) adaptive behav-ior (146,147,150). Adaptive behaviors or activities of dailyliving are not routinely assessed in the school setting apartfrom evaluations for students with serious developmentaldelay. For students with TBI, the activities of daily living(e.g., independent skills in walking, talking, getting dressed,going to school, going to work, preparing a meal, cleaningthe house, and adapting to the demands of one’s environ-ment) might be compromised by injury and need to beaddressed.

Comprehensive AssessmentWithin the student’s school, home, and community, func-tional domains to be assessed include cognition, language,memory and concentration, sensory recognition and percep-tion, academic achievement, behavior, and personality. Inaddition to input from parents and educators, a neuropsy-


TABLE 37-2 Tests Commonly Used with Students with Traumatic Brain Injury

DOMAIN TEST

Cognition • Cognitive Assessment System (152)• Comprehensive Test of Nonverbal Intelligence, 2nd ed. (153)• Differential Abilities Scale, 2nd ed. (154)• Kaufman Assessment Battery for Children, 2nd ed. (155)• Stanford-Binet Intelligence Scales, 5th ed. (156)• Wechsler Preschool and Primary Scale of Intelligence, 3rd ed. (157)• Wechsler Abbreviated Scale of Intelligence (WASI) (158)• Wechsler Intelligence Scale for Children, 4th ed. (159)• Woodcock Johnson, 3rd ed.; Tests of Cognitive Abilities (160)

Neurospsychological • Children’s Category Test (161)• Functional Independence Measure (FIM) (162)• ImPACT (Immediate Postconcussion Assessment and Cognitive Testing) (163)• NEPSY-II, 2nd ed. (164)• Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) (165)

Memory Children’s Memory Scale (166)Continuous Performance Test-II (167)Logical Memory I and II (168)Wechsler Memory Scale–IV (169)Wide Range Assessment of Memory and Learning 2 (WRMAL2) (170)

Executive function Behavior Rating Inventory of Executive Function (BRIEF) (171)Delis-Kaplan Executive Function System (172)Executive Control Battery (173)Stroop Color and Word Test (174)Trail Making Test—Part B (175)Wisconsin Card Sorting Test (176)

Attention/concentration Delayed Gratification Task (177)Digit Span (Forward and Reversed) (Wechsler scales) (178)

Language/verbal learning Boston Naming Test (179)Children’s Auditory Verbal Learning Test (180)Multilingual Aphasia Examination (181)Token Test—Short Form (182)

Visual perception Developmental Test of Visual Perception, 2nd ed. (183)Test of Visual Perceptual Skills (184)

Academic-general Kaufman Tests of Educational Achievement, 2nd ed. (185)Peabody Individual Achievement Test-III (186)Wechsler Individual Achievement Test, 3rd ed. (187)Woodcock Johnson, 3rd ed.; Tests of Academic Achievement (188)

Academic-targeted Key Math Diagnostic Test (189)Woodcock Reading Mastery Tests, 3rd ed. (190)

Behavior Child Behavior Checklist (ASEBA Preschool and School Age) (191)

Social behavior Behavior Assessment System for Children, 2nd ed. (BASC-II) (192)School Social Behavior Rating Scale (SSBR) (193)

Adaptive behavior Adaptive Behavior Assessment System, 2nd ed. (ABAS-II) (194)Scales of Independent Behavior-Revised (SIB-R) (195)Vineland Adaptive Behavior Scales, 2nd ed. (VABS-II) (196)

Motor skills Grooved Pegboard (197)

chologist, school psychologist, or other certified specialistmay use individually-administered tests to assess the stu-dent’s skills in the aforementioned domains. Two recent re-views (146,151) provide examples of the neuropsychologicaland psychoeducational tests used in schools (Table 37-2).

These batteries or more narrowly focused tests shouldbe used, when necessary, to target specific areas of suspecteddisability or concern in conjunction with observation, behav-ior checklists, curriculum-based measurement, and other

context-based measures as described earlier. Many of theaforementioned tests require standardized administration,including timed tasks, specific cut-off points, and scriptedinstructions for items in order to provide scorable resultsbased on testing norms. However, students with brain injuryoften require additional time to process information, andwould be penalized for slow or partial responses on suchstandardized measures. If the goal of the assessment is tocompare the student’s performance with typically develop-

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ing peers, then measures should be administered as directed.If, however, the goal is to gather information about thestudent’s ability to perform given appropriate accommoda-tions and modifications (additional time on tests), then theefficacy of various accommodations could tested during theassessment.

Special Test ConsiderationsPrior to assessment, examiners should be familiar withstrategies to address potential problems confronting manystudents with TBI. These include cognitive and physical fa-tigue (198–199), attention deficits (200), memory problems(201), delayed processing and response time, low motivationor apathy (202), and impulse control deficits. For example,a test requiring extended focus and engagement may be bro-ken into subtests administered at separate times to minimizecognitive fatigue. Attention problems may be managed moreeffectively in a quiet setting with few distractions (hallwaynoise, clocks, alarms, people entering and leaving the room),and may require more frequent and consistent reinforcementof student effort with age-appropriate positive contingencies(203). For tests that are untimed, examiners should allowthe student sufficient time to respond to questions. Potentialproblems with motivation could be addressed prior to test-ing by asking parents or teachers to identify things that arereinforcing to the student (202,204). If the test is nonstandar-dized (or administered in a nonstandard way) students withshort-term memory deficits may benefit from precorrections(reminders of the expected response type) before each re-sponse set. Examiner awareness of the challenges often asso-ciated with TBI can help build therapeutic rapport with thestudent so that a valid sample of performance is obtainedduring testing.

Individual Education Plan DevelopmentOnce a student is found eligible for special education ser-vices, the team (including parents) develops the student’sIEP that describes the type and amount of specially designedinstruction, the settings in which instruction takes place, andany accommodations or related services the student needsto benefit from school. Related services could include in-struction from a speech-language pathologist, a behavioralplan for the classroom, and/or participation in a social skillsgroup. The IEP written for a child with TBI will require pro-cedures that vary from traditional IEP development in sev-eral ways (205). Because of the underlying medical cause ofthe disability, the initial IEP requires a joint venture amongthe health care facility, the school, and the family. Informa-tion from a variety of sources and disciplines outside theschool system needs to be translated and used to determinethe child’s current levels of functioning. Rapidly changingneeds will require the child’s IEP review to be conductedmore frequently than required by law (e.g., every 3–4months initially).

Related ServicesIdeally, students returning to school following a TBI haveaccess to a variety of concomitant outpatient services withtherapists specially trained to serve pediatric and adolescentTBI populations. Unfortunately, although access to such

services is sometimes available in large urban settings (if thechild has the appropriate insurance or qualifies for govern-ment assistance), in reality there is generally a lack of suchservices for most children in the school setting (206,207).

A variety of supportive services that may be requiredto assist the child to benefit from special education are alsoavailable through IDEA. These related services can includephysical therapy, occupational therapy, speech-languagetherapy, audiology services, psychological services, recrea-tion therapy, counseling services, social work services,school health services, parent counseling and training, andtransportation.

As a child with TBI transitions from the hospital/reha-bilitation setting back to school, questions often arise as tofunding sources for related services, as there is no clear de-marcation between rehabilitation services and those servicesthat are a necessary part of the child’s education. Accordingto IDEA, children are entitled to receive ‘‘related services’’deemed ‘‘educationally relevant.’’ How individual districtsinterpret educational relevance is often open to debate. Forexample, a school district might argue that physical therapyto increase the head control of a student who is severelyinjured is rehabilitation therapy; others could argue that itis educationally relevant therapy because increasing headcontrol might allow the student to use a head switch to accessa computer in the school setting. In many cases, as studentswith TBI transition from the medical or rehabilitation settingto school, they receive a combination of educationally basedtherapy at school and outpatient medical therapy that is paidfor by their insurance providers or Medicaid.

Special Education Placements and SettingsAlthough IDEA requires that students with disabilities, in-cluding TBI be educated in the least restrictive environment(LRE) ‘‘to the maximum extent possible,’’ a full continuumof options regarding where children can receive services isavailable. This can include general education classes, specialeducation classes (e.g., resource rooms, self-containedclasses), special education schools, hospitals, public or pri-vate institutions, and instruction at home. There are manyfactors to consider in making a decision about the LRE deci-sion and there are no standardized procedures to follow(208–210). However, IEP teams can use both case law andguidelines put forward by researchers who have examinedLRE placement policy to inform their decision-making (e.g.,Cheatham et al. [211]; Rozalski and Stewart [212]). In general,the child’s team, based on considerations of the child’sunique needs and the LRE in which those needs can be ad-dressed, makes placement decisions. Frequent progressmonitoring of student performance is helpful in guidingchanges and adaptations in support provided, which mightinclude changes in instructional setting and content.

For example, a school team may decide that a studentreturning to school with moderate deficits in memory, pro-cessing speed, and verbal comprehension following a TBImay best be served in the general education classroom withsupport from the special education teacher delivered withinthe child’s own classroom. In another case, a school teammay determine that the most appropriate placement for astudent with severe language and learning problems as aresult of a TBI is a self-contained classroom in the student’shome school. There the student can receive more needed

AQ4


one-on-one learning time, yet still participate with generaleducation peers in daily activities such as lunch, recess, art,and music class. In keeping with the intent of the law, it isunusual for a school team to recommend a placement suchas a special day school or residential placement. Theseoptions are costly and are not available in many areas. More-over, with school systems currently serving a number of stu-dents who have severe or profound disabilities as a resultof various conditions, the medical needs of the child withTBI should not be a hindrance to an education in the LRE.In some cases, a residential placement or special school maybe necessary if a school district is unable to provide supportsthat allow the student to benefit from the educational pro-gram. In the end, the child’s IEP team, including medicaland rehabilitation providers who have treated the student,must consider the specific needs of the student, the qualityand type of resources available within the school district,and the legal mandate to place the child in the LRE to makesrecommendations about school placement.

Specially Designed InstructionRegardless of the setting, the term special education involves‘‘specially designed instruction,’’ which IDEA defines as in-struction that ‘‘adapts the content, methodology, or deliveryof instruction to address the unique needs of the child thatresult from the child’s disability’’ [34 CFR §300.39(b)(3)]. Thepurpose of the specially designed instruction is to ensurethe child gains access to the general curriculum so that heor she can meet the educational standard that applies to all

TABLE 37-3 Evidence-Based Instructional Practices and Strategies (132)

INSTRUCTIONAL STRATEGY DESCRIPTION TBI CHARACTERISTIC

Appropriate pacing Delivering material in small increments and requiring • Fluctuating attentionresponses at a rate consistent with a student’sprocessing speed increases acquisition of newmaterial

• Decreased speed of processing

High rates of success Acquisition and retention of new information tends to • Memory impairmentincrease with high rates of success

• High rates of failure

Task analysis Careful organization of learning tasks, including • Organizational impairmentsystematic sequencing of teaching targets

• Inefficient learning

Sufficient practice and Acquisition and retention of new information is • Inefficient learningreview (including increased with frequent reviewcumulative review)

• Inconsistency

Corrective feedback Learning is enhanced when errors are followed by • Inefficient feedback loopsnonjudgmental corrective feedback

• Implicit learning of errorsTeaching to mastery Learning is enhanced with mastery at the acquisition • Possibility of gaps in the knowledge base

phaseFacilitation of Generalizable strategies and general case teaching • Frequent failure of transfer

generalization (wide range of examples and settings) increasesgeneralization

• Concrete thinking and learning

Ongoing assessment Adjustment of teaching based on ongoing assessment • Inconsistencyof students’ progress facilitates learning

• Unpredictable recovery

children within the jurisdiction of the public agency (schooldistrict or state). Although there is very little empirical evi-dence of the effectiveness of interventions to promote posi-tive educational outcomes for children and youth followinga TBI (213,214), a number of promising practices can be iden-tified from research with children with other disability labels(131,144). Because children with TBI share commonalitieswith children with other disabilities, this research can pro-vide guidance for educators working with students with TBI.

Perhaps the most critical factor in educating studentswith TBI is ensuring high levels of accuracy in their academicwork; there is a strong correlation between maintaining highrates of learner success and increased acquisition and reten-tion of newly learned information (215–217). The provisionof guided practice (218–221) and cumulative review (222)address inefficient and inconsistent learning characteristicsof students with TBI. Students with TBI also benefit fromusing well-rehearsed instructional routines or strategies. In-structional routines consist of a set of steps applicable acrossa range of examples (e.g., consistent sequence of steps forsolving math story problems) (218,221,223). Brisk instruc-tional pacing, appropriately adjusted to the student’s re-sponse rate, can increase the acquisition rate of new material(224). Providing systematic corrective feedback (225,226) isimportant for students with learning and memory problemsafter TBI (216,227,228); immediate, nonjudgmental feedbackis critical to improving accuracy when the task is presentedagain. Table 37-3 presents a summary of research-based in-structional strategies that address cognitive characteristicscommon to many students with TBI.


In addition to the evidence supporting specific instruc-tional strategies, there is substantial research on the efficacyof metacognitive interventions in promoting student success(217,218). Designed to facilitate a strategic approach to diffi-cult academic tasks, metacognitive strategies are proceduresthat students can use to improve their performance acrossa variety of academic tasks. Strategies can be task specificor more general. For example, a self-regulatory self-talkstrategy like ‘‘I need to check my work’’ is generally applica-ble to a wide variety of academic tasks. Using a graphicorganizer for writing a story is an example of a metacognitivestrategy that is task-specific.

Educational AccommodationsEducational accommodations allow students with disabili-ties to access the same curriculum as their peers throughchanges in teaching methods and/or materials. For example,a student with memory problems may require multisensorypresentations or a child with vision deficits may require largeprint books to be able to work towards the same goals astheir classmates in the general education classroom. Chil-dren returning to a general education setting following TBIwill more than likely require multiple accommodations.Table 37-4 presents examples of educational accommoda-tions that address cognitive and physical characteristics com-mon to many students with TBI. These accommodations canbe successfully employed in general education settings or inthe context of special education environments. Accommoda-

TABLE 37-4 Educational Accommodations

COMMON DEFICITSFOLLOWING TBI CLASSROOM EXAMPLES POSSIBLE ACCOMMODATIONS

Fatigue Student struggles to stay alert in class; physical ex- Modified school day; schedule most taxing courseshaustion impacts student’s learning early in day; rest breaks

Attention/concentration Student is unable to sustain or maintain focus to Reduce distractions in student’s work area; dividecomplete task or activities; is easily distracted; if work into smaller sections; use verbal or nonverbalinterrupted cannot go back and pick up where cueing system to remind student to pay attentionhe or she left off

Memory Student has difficulty remembering instructions; is Provide written instructions for student; shortenable to read assigned chapter, but cannot recall reading passages; frequently repeat and summa-what was read; does well on daily assignment, rize information; link new information to student’sbut poorly on tests relevant prior knowledge

Organization Student is often late to class; comes to class without Assign person to review schedule at start of schoolnecessary materials; does not automatically carry day and organize materials for each class; useout the class schedule; does not remember what color-coded materials for each class (book, note-class is next; leaves out steps in a project or when book, supplies); provide written schedule of dailysolving a complex problem routine and give reinforcement for referring to

schedule; provide written checklist for complextasks

Processing speed When called on in class, student does not respond Give student advanced notice he or she is going toright away, gives appearance of not attending or be called on; allow extra time for the student toknowing the answer; has difficulty carrying out respond when answering; supply written set of di-multi-step directions; performs poorly on timed rections; provide extended time on assignmentstests and tests

Visual–motor Student has difficulty copying problems from the Assign someone to take notes for student during lec-blackboard; decreased motor speed makes tures; provide copy of problems on blackboard;keeping up with taking lecture notes impossible; allow for alternatives to paper-pencil writing (oralvisual field deficit causes student to ignore infor- responses, computer); provide preferential seat-mation presented on right side ing to maximize visual field

tions such as these minimize the student’s deficits and allowhim or her to remain in a less restrictive school environment.

Behavioral and Social Support StrategiesIndividual education plans for students with TBI often in-clude social and behavioral goals, as difficulties with EF,including impulse control and control of attention, are com-mon sequelae of TBI (22,24,203). Addressing behavioral chal-lenges is often difficult and time intensive for school staff,however, appropriate school and social behavior is criticalto student success (229). There is a large research base onstrategies to support students with behavioral issues includ-ing Functional Behavior Assessment; monitored trials of ac-commodations and modifications, for example, modifiedschedule, preferential seating, and so forth; small group in-struction; and individual behavioral interventions (230). Col-laboration with district or outside agency specialists suchas vocational rehabilitation counselors, transition specialists,therapists, and so forth, may also be useful (146). Table37-5 includes validated approaches to behavioral and socialintervention.

504 EligibilityAlthough TBI often affects learning, not all students withTBI need, or are eligible for, assistance under IDEA. Somestudents are able to participate in the general education pro-gram with supports and accommodations provided through


TABLE 37-5 Integrated Approaches to Behavioral and Social Intervention (132)

APPROACH DESCRIPTION TBI CHARACTERISTIC

Self-awareness/ Facilitation of students’ understanding of their • Decreased self-awarenessattribution training role in learning; validated for students with • Denial of deficits

learning difficulties (231)

Cognitive behavior Facilitation of self-control of behavior; validated • Weak self-regulation related to frontal lobemodification with adolescents with ADHD and aggressive injury

behavior (232) • Disinhibited and potentially aggressive behavior

Positive, antecedent- Approach to behavior management that focuses • Impulsive behaviorfocused behavior primarily on the antecedents of behavior (in a • Inefficient learning from consequencessupports broad sense); validated in developmental • History of failure

disabilities and with some TBI subpopulations • Defiant behavior(233,234) • Initiation impairment

• Working memory impairment

Circle of friends A set of procedures designed to support • Frequent loss of friendsstudents’ social life and ongoing social • Social isolationdevelopment; validated in developmental • Weak social skillsdisabilities and TBI (235,236)

Abbreviations: ADHD, attention deficit hyperactivity disorder.

a Section 504 plan (237). This civil rights act protects individ-uals from discrimination based on their disability, ensuringindividuals’ equal rights to participate in and have access toprogram benefits and services, including public education.The definitions of disability in this law are broader and moreinclusive than those in IDEA; an individual with a disabilityis someone with a physical or mental impairment that sub-stantially limits 1 or more major life activities, such as caringfor oneself, walking, seeing, hearing, speaking, breathing,working, performing manual tasks, and learning (238). TheRehabilitation Act Section 504 is a civil rights law that appliesto all settings, not just public school, so it continues to protectindividuals from discrimination after high school gradua-tion. A written 504 plan might include accommodations toaddress physical, cognitive, or behavioral needs, including,for example, a reduced schedule to compensate for fatigue,a note taker for fine motor difficulties, or increased time tocomplete tests and assignments to compensate for process-ing delays.

Transition Planning or ServicesUnder IDEA, transition services are mandated for all stu-dents with disabilities beginning at age 16 (141). The lawspecifies that each student have an IEP to facilitate move-ment from school to post-school life, that the plan take intoaccount the student’s abilities, preferences, and interests, andinclude measurable postsecondary goals (239). The planmust include instruction, services, experiences, developmentof objectives for employment and adult living, and acquisi-tion of living and vocational skills. The National SecondaryTraining and Technical Assistance Center (NSTTAC) recom-mends that transition plans incorporate the following evi-dence-based practices: (a) transition planning focused onpost-school goals and self-determination; (b) help coordinat-ing postsecondary plans with adult agencies; (c) instructionin academic, vocational, independent living, and per-sonal–social content areas; (d) support for completing highschool; and (e) paid job training while in the program and

help securing employment or entering postsecondary train-ing on leaving the program (240).

Building Capacity of Educators: Recommendationsfor Teacher Training

There continues to be a lack of awareness of the impact ofTBI on school performance (112). Numerous resources existfor educators who want to learn more about childhood TBI(e.g., http://cokidswithbraininjury.com/, http://www.la-publishing.com, http://www.projectlearnet.org/, http://www.brainlinekids.org/). Further, with the increased aware-ness of the impact of concussion on young learners and theneed for schools to address these students’ needs, a varietyof new resources have been developed (e.g., http://brain101.orcasinc.com/, http://www.cdc.gov/concussion/HeadsUp/schools.html).

The challenge remains that many teachers leave theiruniversity training programs with little or no training in TBI(241–243). Training for general education teachers in work-ing with students with TBI is minimal (109,110,244), andmost special education teacher preparation programs offertraining in strategies designed to support students withhigher incidence disabilities (e.g., Specific Learning Disabil-ity and attention-deficit/hyperactivity disorder) (245).

More comprehensive teacher training efforts in TBI havefocused on training educators who are currently working inschools (137,138). The past 30 years of research on profes-sional development for educators points to a number of criti-cal components for effectiveness regardless of the particularsubject or method being taught. To have an impact on stu-dents, training and support for educators must

� require teachers to practice new skills in the school envi-ronment (246–250);

� provide access to sufficient organizational supports(251);

� include information about the causes, incidence, treat-ment, outcomes, and challenges of TBI;


� include a variety of evidence-based strategies (252,253);� include consultation on implementation of new skills in

the instructional setting (e.g., Bowen [254]; Fuchs andFuchs [255]; Gersten et al. [256]; Sailors and Price [257]);and

� be of sufficient duration (e.g., 7–8 sessions) to producelong-term sustained use of new strategies in the instruc-tional setting (250,258,259).

There are currently 2 teacher training models that incor-porate these features in use with educators serving studentswith TBI: the TBI Consulting Team model (137) and Brain-STARS (260–262). Although these models show promise,both lack evidence of impact on child outcome, which isthe standard for evaluating the effectiveness of professionaldevelopment models (263–265).

CONCLUSION

Although hospitals treat children and adolescents with TBIin their initial course of recovery, it is ultimately the schoolsystem that serves as the long-term provider of services forthis population. Because TBI has significant and on-goingeffects on academic, cognitive, and psychosocial functioning,in 1991 TBI was added to the list of disabilities that qualifystudents for special education services under IDEA, and thusstudents, if identified, can receive an array of supports toaddress individual needs. However, despite the fact that thefoundation for providing appropriate service to studentswith TBI exists in special education law, students with TBIcontinue to experience significant challenges in school andas a group experience poor PSO.

For students with TBI, school performance is most oftenaffected by executive dysfunction, social behavioral prob-lems, and a progressive lag in academic achievement. Sev-eral factors have been found to mediate and moderate theeffect of TBI on school performance. Early injury is associ-ated with poorer outcomes than later injury, and generallymore severe TBI is associated with more negative outcomes.Family environmental characteristics, such as SES, overallfamily functioning, and parenting behavior can also signifi-cantly affect student educational performance. In addition tochild- and family-centered factors, a range of environmentalvariables negatively affect student outcomes. For example,the lack of training in TBI for educators, as well as ineffectivehospital–school communication, has led to underidentifica-tion of children with TBI for special education. Adversarialparent–educator relationships have often hampered the de-sign of educational programs for students with TBI.

Like other students with disabilities, students with TBIneed and deserve to be promptly and accurately identifiedso they can be appropriately served by educators who areknowledgeable about the challenges they experience andwho can implement effective instructional and behavioralstrategies. Because most parents of students with TBI willhave had no prior experience with special education, schoolsystems should provide information and link parents withskilled advocates. Linking students with TBI and their fami-lies to community-based resources—throughout their schoolyears but especially at transition from high school—shouldbe a high priority for the IEP team.

These improvements in service delivery will involvesystemic changes. Well-developed preservice and in-servicetraining programs for school personnel will help educatorsaccurately identify students with TBI, implement effectiveeducational practices, develop strategies for collaboratingwith parents, and link students to appropriate community-based supports as they leave high school. Well-establishedhospital–school linkages with school reentry protocols willhelp to increase identification rates and ensure smooth tran-sitions back to school. Significantly improving outcomes forstudents with TBI will require comprehensive research ef-forts that examine these and other efficacious interventionsand bringing these interventions into broader use througha coordinated process of development, training, technicalassistance, and dissemination.

KEY CLINICAL POINTS

1. Reduced hospital stays has resulted in children with sig-nificant needs returning to school with little or no supportfrom medical or community-based agencies; the primaryservice provider for children and adolescents has becomethe school.

2. For students with moderate to severe injury, the rate ofacademic achievement gains tends to slow progressivelyover time, and the effects are long-term. Changes in socialbehavior affect not only functional aspects of daily livingbut also quality of life.

3. A growing body of research indicates that post-highschool outcomes for many students with TBI are poor.

4. Effective instructional and behavioral support strategiesimplemented by trained educators can help mitigate theacademic and behavioral challenges associated withchildhood TBI.

5. Instructional methodologies that have proven effectivewith learners with different disability labels but similarfunctional challenges can be used effectively with stu-dents with TBI.

6. Improve identification of students with TBI for specialeducation services could lead to more effective provisionof educational and social/behavioral support strategiestailored to students’ specific needs.

7. To lead to positive student outcomes, training and supportfor educators must include training in evidence-based in-terventions, supervised practice in both the training siteand classroom, and continued mentoring, feedback, andconsultation in the classrooms.

KEY REFERENCES

1. Babikian T, Asarnow R. Neurocognitive outcomes andrecovery after pediatric TBI: meta-analytic review of theliterature. Neuropsychology. 2009;23(3):283–296.

2. Taylor HG, Swartwout MD, Yeates KO, Walz NC, StancinT, Wade SL. Traumatic brain injury in young children:postacute effects on cognitive and school readiness skills.J Int Neuropsychol Soc. 2008;14(5):734–745.

3. Todis B, Glang A, Bullis M, Ettel D, Hood D. Longitudinalinvestigation of the post-high school transition experi-


ences of adolescents with traumatic brain injury. J HeadTrauma Rehabil. 2011;26(2):138–149.

4. Yeates KO, Anderson V. Childhood traumatic brain in-jury, executive functions, and social outcomes: toward anintegrative model for research and clinical practice. In:Anderson V, Jacobs R, Anderson PJ, eds. Executive Func-tions and the Frontal Lobes: A Lifespan Perspective. Philadel-phia, PA: Taylor & Francis; 2008:243–267.

5. Ylvisaker M, Todis B, Glang A, et al. Educating studentswith TBI: themes and recommendations. J Head TraumaRehabil. 2001;16(1):76–93.

RECOMMENDED WEBSITES

http://www.cbirt.orghttp://www.LearNet.orghttp://www.cokidswithbraininjury.com

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